Medicolegal and Bioethics Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Euthanasia and assisted suicide: a physician’s and ethicist’s perspectives J Donald Boudreau1 Abstract: The debate on legalizing euthanasia and assisted suicide has a broad range of Margaret A Somerville2 participants including physicians, scholars in ethics and health law, politicians, and the general public. It is conflictual, and despite its importance, participants are often poorly informed or 1Faculty of Medicine, Department of Medicine, McGill University, Montreal, confused. It is essential that health care practitioners are not among the latter. This review QC, Canada; 2Faculty of Law, Faculty responds to the need for an up-to-date and comprehensive survey of salient ethical issues. of Medicine, and Centre for Medicine, Ethics and Law, McGill University, Written in a narrative style, it is intended to impart basic information and review foundational Montreal, QC, Canada principles helpful in ethical decision-making in relation to end-of-life medical care. The authors, a physician and an ethicist, provide complementary perspectives. They examine the standard arguments advanced by both proponents and opponents of legalizing euthanasia and note some recent legal developments in the matter. They consider an aspect of the debate often underappreciated; that is, the wider consequences that legalizing euthanasia might have on the Video abstract medical profession, the institutions of law and medicine, and society as a whole. The line of argument that connects this narrative and supports their rejection of euthanasia is the belief that intentionally inflicting death on another human being is inherently wrong. Even if it were not, the risks and harms of legalizing euthanasia outweigh any benefits. Ethical alternatives to euthanasia are available, or should be, and euthanasia is absolutely incompatible with physi- cians’ primary mandate of healing. Keywords: euthanasia, physician assisted-suicide, healing, suffering, palliative care, palliative sedation Introduction Point your SmartPhone at the code above. If you have a One of us (JDB) was recently attending on a clinical service where a situation arose QR code reader the video abstract will appear. Or use: http://dvpr.es/1n0869C that prompted a discussion concerning assisted suicide. It revealed a surprising lack of consensus among physicians regarding the difference between assisted suicide and euthanasia, as well as an appalling level of confusion about basic facts. Such a situation is disconcerting, given that good ethical decision-making requires “getting the facts straight” as an essential first step. It may be understandable that personal perspectives will vary on matters such as physician-assisted suicide (PAS) and euthanasia, particularly in our pluralistic societies. However, it is unacceptable that conversations of a profes- Correspondence: J Donald Boudreau sional nature would proceed in the absence of agreement on relevant first principles Center for Medical Education, Faculty and without a shared knowledge base. It would be akin to a cadre of interventional of Medicine, McGill University, cardiologists, equipped with a shaky grasp of the vascular anatomy of the myocardium, 1110 Pine Ave West, Montreal, QC, H3A 1A3, Canada debating the merits of an innovative approach to intracoronary stenting. Tel +1 514 398 5613 This article addresses such lacunae in relation to euthanasia and PAS. (We will use Fax +1 514 398 7246 Email [email protected] the word euthanasia to include PAS except where we state otherwise or it is clear we submit your manuscript | www.dovepress.com Medicolegal and Bioethics 2014:4 1–12 1 Dovepress © 2014 Boudreau and Somerville. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/MB.S59303 permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Boudreau and Somerville Dovepress are dealing with the issues separately). We define euthanasia with the intention of ending the life of another person in order and assisted suicide, reveal common misconceptions in to relieve that person’s suffering.”7 this regard, and expose euphemisms that, regrettably, often Terms such as active and passive euthanasia should be serve to confuse and deceive. We review the main argu- banished from our vocabulary. An action either is or is not ments advanced by proponents and opponents of legalizing euthanasia, and these qualifying adjectives only serve to euthanasia. The philosophical assumptions guiding our per- confuse. When a patient has given informed consent to a spectives are laid out. We consider the effect of legalization lethal injection, the term “voluntary euthanasia” is often on patients and their families, physicians (as individuals and used; when they have not done so, it is characterized as a collectivity), hospitals, the law, and society at large. Our “involuntary euthanasia”. As our discussion of “slippery goal is to provide a vade mecum useful in end-of-life care slopes” later explains, jurisdictions that start by restricting and ethical decision-making in that context. legalized euthanasia to its voluntary form find that it expands into the involuntary procedure, whether through legalizing the Definitions latter or because of abuse of the permitted procedure. Euthanasia In the Netherlands, Belgium, and Lichtenstein, physi- Euthanasia is an emotionally charged word, and definitional cians are legally authorized, subject to certain conditions, to confusion has been fermented by characterizations such as administer euthanasia. For the sake of clarity, we note here passive versus active euthanasia. Some have suggested avoid- that outside those jurisdictions, for a physician to administer ing using the word altogether.1,2 We believe it would be a euthanasia would be first-degree murder, whether or not the mistake to abandon the word, but we need to clarify it. patient had consented to it. The word’s etymology is straightforward: eu means good and Thanatos means death. Originally, euthanasia meant the Assisted suicide condition of a good, gentle, and easy death. Later, it took on Assisted suicide has the same goal as euthanasia: causing the aspects of performativity; that is, helping someone die gently. death of a person. The distinction resides in how that end is An 1826 Latin manuscript referred to medical euthanasia as achieved. In PAS, a physician, at the request of a competent the “skillful alleviation of suffering”, in which the physician patient, prescribes a lethal quantity of medication, intending that was expected to provide conditions that would facilitate a the patient will use the chemicals to commit suicide. In short, gentle death but “least of all should he be permitted, prompted in assisted suicide, the person takes the death-inducing product; either by other people’s request or his own sense of mercy, in euthanasia, another individual administers it. Both are self- to end the patient’s pitiful condition by purposefully and willed deaths. The former is self-willed and self-inflicted; the deliberately hastening death”.3 This understanding of eutha- latter is self-willed and other-inflicted. Although the means vary, nasia is closely mirrored in the philosophy and practice of the intention to cause death is present in both cases. contemporary palliative care. Its practitioners have strongly Some will argue that agency is different in assisted suicide rejected euthanasia.4 and euthanasia; in the former, the physician is somewhat Recently, the noun has morphed into the transitive verb removed from the actual act. To further this goal, two ethicists “to euthanize”. The sense in which physicians encounter it from Harvard Medical School in Boston, Massachusetts, today, as a request for the active and intentional hastening of USA, have proposed strategies for limiting physician involve- a patient’s demise, is a modern phenomenon; the first sample ment in an active death-causing role.8 It is, indeed, the case sentence given by the Oxford English Dictionary to illustrate that patients provided with the necessary medication have the use of the verb is dated 1975.5 The notion of inducing, ultimate control over if, when, and how to proceed to use it; causing, or delivering a (good) death, so thoroughly ensconced they may change their mind and never resort to employing in our contemporary, so-called “progressive values” cultural it. However, in prescribing the means to commit suicide, the ethos, is a new reality. That fact should raise the question: physician’s complicity in causing death is still present. There “Why now?” The causes go well beyond responding to the are, however, some limits on that complicity, even in the suffering person who seeks euthanasia, are broad and varied, jurisdictions where it has been legalized. For instance, even and result from major institutional and societal changes.6 supporters of PAS in those jurisdictions agree it is unethi- Physicians need a clear definition of euthanasia. We cal for physicians to raise